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Minimal intratumoral heterogeneity in untreated cancers

Genetic intratumoral heterogeneity is a natural consequence of imperfect DNA replication. Any two randomly selected cells, whether normal or cancerous, are therefore genetically different. I will discuss the extent of genetic heterogeneity within untreated cancers with particular regard to its clinical relevance. While genomic heterogeneity within primary tumors is associated with relapse, heterogeneity among treatment¿naïve metastases has not been comprehensively assessed. We analyzed sequencing data for 76 untreated metastases from 20 patients and inferred cancer phylogenies for breast, colorectal, endometrial, gastric, lung, melanoma, pancreatic, and prostate cancers. We found that within individual patients a large majority of driver gene mutations are common to all metastases. Further analysis revealed that the driver gene mutations that were not shared by all metastases are unlikely to have functional consequences. A mathematical model of tumor evolution and metastasis formation provides an explanation for the observed driver gene homogeneity. Last, we found that individual metastatic lesions responded concordantly to targeted therapies in 91% of 44 patients. These data indicate that the cells within the primary tumors that gave rise to metastases are genetically homogeneous with respect to functional driver gene mutations and suggest that future efforts to develop combination therapies have the capacity to be curative.